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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286802049
Report Date: 09/30/2025
Date Signed: 09/30/2025 01:22:22 PM

Document Has Been Signed on 09/30/2025 01:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:VINTAGE HOUSEFACILITY NUMBER:
286802049
ADMINISTRATOR/
DIRECTOR:		ROA, FRANCISCOFACILITY TYPE:
740
ADDRESS:2541 VINTAGE STREETTELEPHONE:
(707) 265-8652
CITY:NAPASTATE: CAZIP CODE:
94558
CAPACITY: 6CENSUS: 5DATE:
09/30/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Responsible Party - Catalina Bueno-SalcedoTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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At approximately 9:45 AM, Licensing Program Analyst (LPA) Star Stevenson BEGAN a required 1-year unannounced inspection of this licensed senior care facility. LPA met with caregiver Catalina Bueno-Salcedo (formerly associated with Vintage House as Catalina Sanchez) who has Designation of Facility Responsibility (RP). Catalina called licensee Roa Francisco who was not able to attend today's inspection and agreed to have inspection continue with RP. Vintage house is a Residential Care Facility for the Elderly (RCFE) with capacity for six (6) residents and can care for four (4) non-ambulatory residents in rooms one (1), two (2), & four (4) and has a hospice waiver for two (2).

At approximately 10:20 AM, LPA toured the building and grounds which was found to be a comfortable temperature and without odors. LPA observed all walkways and exits to be unobstructed. LPA observed facility now has resident rights posted. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored and not accessible. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguisher inspected was charged and last inspected November 2024. Smoke detectors and carbon monoxide detectors were found to be in working order. Medicines are locked in entryway closet and no evidence of pre-pouring was observed. Licensee was advised to remove clear plastic tape and repair main bathroom threshold to reduce tripping hazard among elderly residents.
Continued on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: VINTAGE HOUSE
FACILITY NUMBER: 286802049
VISIT DATE: 09/30/2025
NARRATIVE
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Continued from LIC809...

At approximately 11:30 AM, LPA reviewed five (5) staff files. Four (4) of five (5) staff files were noted to be missing records with S1 needing evidence of 40 hours of education/training having returned to work at Vintage House, S2 needing evidence of 1st Aid/CPR training, TB clearance, Job application and MD health screening. S3 is missing evidence of 1st Aid/CPR training and evidence of 20 hours of annual training and S5 missing evidence of TB clearance and 20 hours of annual training. (deficiencies cited)

LPA will return at later unannounced date to complete inspection.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

Current Lease Agreement or evidence of Control of Property
LIC308- Updated Designation of Responsibility
LIC500- Personnel Report
LIC610E- Disaster Plan
Updated Evidence of Liability Insurance


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Catalina Bueno Salcedo and Appeal rights were given.
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Star Stevenson
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
Page: 3 of 15
Document Has Been Signed on 09/30/2025 01:22 PM - It Cannot Be Edited


Created By: Star Stevenson On 09/30/2025 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINTAGE HOUSE
FACILITY NUMBER: 286802049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on inteview and record review, the licensee did not comply with the section cited above in two (2) out of five (5) persons missing evidence of TB clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Licensee to submit letter to Community Care Licensing that he has read CCR 87411(f) requiring health screening and specifically TB clearance for all employees and to provide evidence of TB clearance for S2 and S5 or evidence of appointment to be tested.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2025 01:22 PM - It Cannot Be Edited


Created By: Star Stevenson On 09/30/2025 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINTAGE HOUSE
FACILITY NUMBER: 286802049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(13)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on interview and record review the licensee did not comply with the section cited above in one (1) out of five (5) persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Licensee to submit letter to CCL that he has read regulation CCR 87412(a)(13) and provide evidence of attaining Guardian association and fingerprinting clearance for S1
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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2
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2025 01:22 PM - It Cannot Be Edited


Created By: Star Stevenson On 09/30/2025 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINTAGE HOUSE
FACILITY NUMBER: 286802049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on observation, interview and record review the licensee did not comply with the section cited above in four (4) out of five (5) staff records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2025
Plan of Correction
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Licensee to submit letter to CCL that he has read regulation CCR 87412(a) and provide evidence of 1stAid/CPR training for S2 and S3
Type B
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above in 1 (one) out of 5 (five) staff members which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2025
Plan of Correction
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Licensee will submit letter to CCL that he has read regulation CCR 87355(e) and will provide evidence of assisting S1 with their criminal clearance/association.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
Page: 6 of 15
Document Has Been Signed on 09/30/2025 01:22 PM - It Cannot Be Edited


Created By: Star Stevenson On 09/30/2025 at 12:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: VINTAGE HOUSE
FACILITY NUMBER: 286802049

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on inteview and record review the licensee did not comply with the section cited above in three (3) out of four (4) employee records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2025
Plan of Correction
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Licensee to review regulation HSC 1569.625(b)(1) of employees needing intial 40 hours of training and 20 hours of annual training and to provide evidence of on-going training for S1, S3 and S5

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Star Stevenson
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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